Healthcare Provider Details

I. General information

NPI: 1699549709
Provider Name (Legal Business Name): MARCUS DWAYNE BRYAN PH.D, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2023
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 CHERRY ST NE
MARIETTA GA
30060-7205
US

IV. Provider business mailing address

4820 REGENCY TRCE SW
ATLANTA GA
30331-6844
US

V. Phone/Fax

Practice location:
  • Phone: 770-793-5700
  • Fax:
Mailing address:
  • Phone: 678-727-3274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberRN319485
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: